210 R.I. Code R. 210-RICR-50-00-1.3

Current through December 3, 2024

Section 210-RICR-50-00-1.3 - Definitions

A. For the purposes of LTSS Medicaid, the following definitions apply:

1. "Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals" or "BHDDH" means the State agency established under the provisions of R.I. Gen. Laws Chapter 40.1-1 whose duty it is to serve as the State's mental health authority and establish and promulgate the overall plans, policies, objectives, and priorities for State programs for adults with intellectual and developmental disabilities as well mental illness and substance abuse education, prevention and treatment.

2. "Department of Human Services" or "DHS" means the State agency established under the provisions of R.I. Gen. Laws Chapter 40-1 that is empowered to administer certain human services. The DHS has been delegated the authority through an interagency service agreement with the Executive Office of Health and Human Services (EOHHS), the Medicaid Single State Agency, to determine Medicaid eligibility in accordance with applicable State and Federal laws, Rules and Regulations.

3. "Developmental disability" means, for the purposes of the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, a condition that affects a person, eighteen (18) years or older, who is either an intellectually developmentally disabled adult or a person with a severe, chronic disability that:

a. Is attributable to a mental or physical impairment or combination of mental and physical impairments;

b. Manifests before the person attains age twenty-two (22);

c. Is likely to continue indefinitely;

d. Results in substantial functional limitations in three (3) or more of the following areas of major life activity:

(1) Personal care

(2) Communication

(3) Mobility

(4) Learning

(5) Self-direction

(6) Capacity for independent living

(7) Economic self-sufficiency; and

(8) Reflects the person's need for a combination and sequence of special, interdisciplinary, or generic care, treatment or other services which are life-long or of extended duration and are individually planned and coordinated.

4. "Eligibility date" means the first (1^st) day of the month in which a person is eligible for Medicaid LTSS. It is based on the month the application or, for existing beneficiaries, the request for LTSS is made and is otherwise unrelated to the date a person entered an institution or began receiving LTSS, regardless of payer. The eligibility date does not include periods of retroactive eligibility.

5. "Executive Office of Health and Human Services" or "EOHHS" means the State agency established in 2006 under the provisions of R.I. Gen. Laws Chapter 42-7.2 within the executive branch of State government which serves as the principal agency for managing the Departments of Children, Youth, and Families (DCYF); Health (RIDOH); Human Services (DHS); and Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH).

6. "Financial eligibility" means the set of factors used to determine whether a person is entitled to receive services based upon income and/or resource requirements, as well as limitations related to the transfer of assets, which includes both liquid resources and real property, prior to the application for Medicaid LTSS.

7. "Functional disability" means any long-term limitation resulting from an illness, health condition, or impairment that affects a person's ability to perform certain activities of daily living without substantial assistance or supervision.

8. "Home and Community-Based Services" or "HCBS" means any Medicaid LTSS State Plan or Section 1115 waiver-authorized services available to beneficiaries at home or in a community-based setting.

9. "Institution" or "Health institution" means a State-licensed health facility that provides health and/or social services and supports on an in-patient basis. For the purposes of this Rule, the term means long-term care hospitals and treatment facilities (LTH), intermediate care facilities for persons with intellectual disabilities (ICF/ID), and nursing facilities (NF).

10. "Integrated Health Care Coverage Groups" or "IHCC" means any Medicaid coverage group consisting of adults who are eligible based on receipt of Supplemental Security Income (SSI), SSI protected status, the SSI income methodology and a related characteristic (age or disability), or as a result of participation in another Federal or State program, such as the Breast and Cervical Cancer Program. This group includes beneficiaries eligible for community Medicaid (non-long-term care), Medicaid-funded LTSS and the Medicare Premium Payment Program (MPPP).

11. "Integrated Health and Human Services Eligibility System" or "IES" means the State's eligibility system that enables applicants, through a single application, to be considered for multiple health and human service programs simultaneously.

12. "Intermediate Care Facility for Persons with Intellectual/Developmental Disabilities" or "ICF/ID" means a State-licensed health care facility that provides long-term services and supports to persons with intellectual/developmental disabilities.

13. "Katie Beckett eligibility" means an eligibility category that allows certain children under age nineteen (19) who have long-term disabilities or complex medical needs who require an institutional level of care to obtain the Medicaid long-term services they need at home. With Katie Beckett eligibility, only the child's income and resources are considered when determining eligibility.

14. "Long-term services and supports" or "LTSS" means a spectrum of services covered by the Medicaid program for persons with clinical and functional impairments and/or chronic illness or diseases that require the level of care typically provided in a health care institution. Medicaid LTSS includes skilled or custodial nursing facility care, therapeutic day services, and personal care as well as various home and community-based services. Medicaid beneficiaries eligible for LTSS are also provided with primary care essential benefits. The scope of these services and supports and the choice of settings is determined by a comprehensive assessment of each person's unique care needs.

15. "LTSS living arrangement" means the institutional or home or community based setting where a Medicaid LTSS beneficiary resides while receiving Medicaid LTSS.

16. "LTSS specialist" means a State agency representative responsible for conducting assessments, determining eligibility for LTSS, authorizing services, and/or providing assistance to people in navigating the Medicaid LTSS system.

17. "Medicaid Affordable Care Coverage Groups" or "MACC" means a classification of persons eligible to receive Medicaid who are subject to the Modified Adjusted Gross Income or "MAGI" standard for determining income eligibility as outlined in the Medicaid Code of Administrative Rules, Medicaid MAGI Financial Eligibility Determinations and Verification (See Part 30-00-5 of this Title).

18. "MAGI standard" means the method for evaluating Medicaid income eligibility using the modified adjusted gross income (MAGI) standard established under the ACA. Persons who are or would be income-eligible for the ACA expansion for adults may obtain Medicaid LTSS if they meet the applicable clinical/functional eligibility criteria, are under age sixty-five (65), and are not eligible for or enrolled in Medicare.

19. "Medicaid single state agency" means the State agency authorized under State law, Title XIX of the U.S. Social Security Act (42 U.S.C. § 1396aet seq.) and the Medicaid State Plan as the entity legally responsible for the program/fiscal management and administration of the Medicaid program. The EOHHS is the designated single State agency in Rhode Island.

20. "Needs-based criteria" means the basis for determining clinical/functional eligibility for Medicaid LTSS. The LTSS needs-based criteria encompass medical, social, functional, and behavioral factors, and the availability of family support and financial resources.

21. "Preadmission Screening and Resident Review" or "PASRR" means the process required by Federal law that evaluates and ensures individuals who have a serious mental illness (SMI) and/or intellectual disability are not inappropriately placed in nursing facilities for long-term care. PASRR requires that those applicants for a Medicaid-certified nursing facility are evaluated for appropriateness.

22. "Primary care essential benefits" means non-LTSS Medicaid health coverage, and includes an array of acute, subacute, and specialty essential benefits, as identified under the Medicaid State Plan, provided by licensed health professionals. These essential benefits include, but are not limited to: health promotion, disease prevention, health maintenance, counseling, patient education, various specialty services and diagnosis and treatment of acute and chronic medical and behavioral health illnesses and conditions in a variety of health care settings such as office visits, inpatient, home care, and day care.

210 R.I. Code R. 210-RICR-50-00-1.3

Amended effective 10/5/2021
Amended effective 12/29/2022